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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-CU6SWT

FACILITY NAME
Bethesda West Clearbrook Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782091
FACILITY ADDRESS
2339 Arbutus St
FACILITY PHONE
(604) 850-7311
CITY
Abbotsford
POSTAL CODE
V2T 2V8
MANAGER
Teresa Guynup

INSPECTION DATE
July 28, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
09:45 AM
DEPARTURE
12:45 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the licensing officer’s observations, review of the facility records, and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
· Licensing · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Program · Care and Supervision · Records and Reporting

As part of this Routine Inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes any noncompliance that was identified during the routine inspection, and a 3 year ‘historical’ review of the facility’s compliance and operation.
Visit the CCFL website at http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: On four occasions during the current month, staff did not comply with the licensees MSAC policies when they did not administer a medication to one person in care as prescribed by their medical practitioner.
Corrective Action(s): Please ensure staff comply with MSAC policies.
Date to be Corrected: Immediately


Comments

The findings of the inspection were reviewed with the facility manager during the inspection and a copy of this report was provided electronically as it was completed off site. No signature was collected.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

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Click here for a description of each "Category" of violation displayed.